Healthcare Provider Details

I. General information

NPI: 1629192158
Provider Name (Legal Business Name): JAMIE MARIE MCDONALD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE PMG AT 8300 CONSTITUTION POB
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-559-6100
  • Fax: 505-559-6101
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI3041
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-3041
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: